Name: a saline/bipolar radiofrequency energy device as an adjunct for hemostasis in solid organ injury/trauma
Uploaded: 2020-07-28T12:30:00
Description: Watch this Scientific Journal Video about A Saline/Bipolar Radiofrequency Energy Device As an Adjunct for Hemostasis in Solid Organ Injury/Trauma at JoVE.com

The authors have no acknowledgments.

Procedures involving animal subjects have been approved by the Animal Care Committee at the University of Calgary and follow the guidelines set by the Canadian Council of Animal Care. The committee ensures the study is ethical and that the animals are treated humanely.
1. Model Preparation
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	<li>House the 50 kg adult male pig in an animal care facility for 1 week prior to the surgery to acclimatize the animal to the housing conditions and the handlers. Fast the model for a minimum of 6 h...

<ol>
	<li>Kauvar, D. S., Lefering, R., Wade, C. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+hemorrhage+on+trauma+outcome:+an+overview+of+epidemiology,+clinical+presentations,+and+therapeutic+considerations.">Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations.</a> Journal of Trauma and Acute Care Surgery. 60 (6), S3-S11 (2006).</li><li>Shrestha, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Damage-control+resuscitation+increases+successful+nonoperative+management+rates+and+survival+after+severe+blunt+liver+injury.">Damage-control resuscitation increases successful nonoperative management rates and survival after severe blunt liver injury.</a> Journal of Trauma and Acute Care Surgery. 78 (2), 336-341 (2015).</li><li>Kozar, R. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trauma+Association/critical+decisions+in+trauma:+operative+management+of+adult+blunt+hepatic+trauma.">Trauma Association/critical decisions in trauma: operative management of adult blunt hepatic trauma.</a> Journal of Trauma and Acute Care Surgery. 71 (1), 1-5 (2011).</li><li>Peitzman, A. B., Richardson, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+injuries+to+the+solid+abdominal+organs:+a+50-year+perspective+from+the+Journal+of+Trauma.">Surgical treatment of injuries to the solid abdominal organs: a 50-year perspective from the Journal of Trauma.</a> Journal of Trauma and Acute Care Surgery. 69 (5), 1011-1021 (2010).</li><li>Aloia, T. A., Zorzi, D., Abdalla, E. K., Vauthey, J. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Two-surgeon+technique+for+hepatic+parenchymal+transection+of+the+noncirrhotic+liver+using+saline-linked+cautery+and+ultrasonic+dissection.">Two-surgeon technique for hepatic parenchymal transection of the noncirrhotic liver using saline-linked cautery and ultrasonic dissection.</a> Annals of surgery. 242 (2), 172-177 (2005).</li><li>Ball, C. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+a+novel+energy+technology+for+arresting+ongoing+liver+surface+and+laceration+hemorrhage.">Use of a novel energy technology for arresting ongoing liver surface and laceration hemorrhage.</a> Canadian Journal of Surgery. 57 (4), E146 (2014).</li><li>Ball, C. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+a+novel+saline/bipolar+radiofrequency+energy+instrument+as+an+adjunct+for+arresting+ongoing+solid+organ+surface+and+laceration+bleeding+in+critically+injured+patients.">Use of a novel saline/bipolar radiofrequency energy instrument as an adjunct for arresting ongoing solid organ surface and laceration bleeding in critically injured patients.</a> Injury. 47 (9), 1996-1999 (2016).</li><li>Ball, C. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+efficacy+of+a+novel+saline/bipolar+radiofrequency+energy+instrument+for+arresting+ongoing+solid+and+non-solid+organ+hemorrhage+in+a+swine+model.">The efficacy of a novel saline/bipolar radiofrequency energy instrument for arresting ongoing solid and non-solid organ hemorrhage in a swine model.</a> Injury. 47 (12), 2706-2708 (2016).</li><li>Swindle, M. M., Smith, A. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Best+practices+for+performing+experimental+surgery+in+swine.">Best practices for performing experimental surgery in swine.</a> Journal of Investigative Surgery. 26 (2), 63-71 (2013).</li><li>Cantle, P. M., Roberts, D. J., Holcomb, J. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Damage+Control+Resuscitation+Across+the+Phases+of+Major+Injury+Care.">Damage Control Resuscitation Across the Phases of Major Injury Care.</a> Current Trauma Reports. 3 (3), 238-248 (2017).</li><li>Gaarder, C., Naess, P. A., Buanes, T., Pillgram-Larsen, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Advanced+surgical+trauma+care+training+with+a+live+porcine+model.">Advanced surgical trauma care training with a live porcine model.</a> Injury. 36 (6), 718-724 (2005).</li><li>Harvin, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Control+the+damage:+morbidity+and+mortality+after+emergent+trauma+laparotomy.">Control the damage: morbidity and mortality after emergent trauma laparotomy.</a> The American Journal of Surgery. 212 (1), 34-39 (2016).</li></ol>

The rapid and effective control of hemorrhage is an essential component of modern damage control resuscitation10. A variety of operative and adjunctive techniques are available to arrest hemorrhage in a solid organ injury3. None of these techniques has proven to be universally applicable or successful in achieving hemostasis. The initial experience with the SBRF device described here has been positive6,7,...

Uncontrolled hemorrhage due to solid organ injury remains a leading cause of morbidity and mortality in both blunt and penetrating trauma1. With the advent of effective damage control resuscitation strategies, the rate of non-operative management for abdominal trauma continues to increase2. As a result, patients requiring operative management have increasingly complex injuries and associated physiologic derangement. In these patients, early control of hemorrhage is an essential component of effective damage control resuscitation and desirable outcomes.
The surgical management of solid organ injuries remains a key competency for trauma, acute care, and general surgeons. A wide variety of surgical techniques and hemostatic adjuncts for these injuries have been described3. Traditional techniques for treating solid organ bleeding include coagulation by high-voltage electrocautery, application of topical hemostatic agents, sutured repairs, and partial or total organ excision. Argon beam coagulation has also been described4. While each of these techniques has a role in achieving hemostasis, none is universally applicable or successful.
Many novel tools and hemostatic therapies have been described in the elective surgical setting. This is especially true in the realm of hepatobiliary surgery5. As familiarity with these tools increases, many of them have also shown promise in the surgical management of traumatic injuries. One such device utilizes a combination of ignited saline and bipolar radiofrequency energy to arrest hemorrhage. Additionally, it has the ability to simultaneously seal small- to medium-sized bile ducts within the liver6. The positive experience with this tool in the management of solid organ injuries has been described previously6,7,8.
The goal of this publication is to demonstrate the potential application of this novel device using simulated solid organ injuries in a porcine model.

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			<td height="21" style="height:21px;width:256px;">Aquamantys pump generator</td>
			<td style="width:173px;">Medtronic</td>
			<td style="width:173px;">40-402-1</td>
			<td style="width:88px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Aquamantys 6.0 bipolar sealer</td>
			<td>Medtronic</td>
			<td>23-112-1</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Electrosurgical pencil with tip</td>
			<td>Megadyne</td>
			<td>0039</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Porcine animal</td>
			<td></td>
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		</tr>
		<tr height="21">
			<td colspan="2" height="21" style="height:21px;">Porcine ventilator/induction and anesthetic medications</td>
			<td></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">2 x 1 liter bags of 0.9% normal saline</td>
			<td></td>
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			<td height="21" style="height:21px;">2 x scalpels (#10)</td>
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			<td height="21" style="height:21px;">Belfour abdominal retractor</td>
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		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Suction tubing</td>
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			<td height="21" style="height:21px;">Suction tip</td>
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		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Suction device/wall connector</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Suction canister</td>
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			<td></td>
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		</tr>
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			<td height="21" style="height:21px;">Debakey forceps</td>
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		</tr>
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			<td height="21" style="height:21px;">Metz scissors</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Curved Mayo scissors</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Closing suture (1-0 Nylon)</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">20 x Laparotomy sponges</td>
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		</tr>
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			<td height="21" style="height:21px;">2 x Kelley clamps</td>
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			<td height="21" style="height:21px;">2 x snap clamps</td>
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		</tr>
	</tbody>
</table>

a saline/bipolar radiofrequency energy device as an adjunct for hemostasis in solid organ injury/trauma

Solid organ (liver, spleen, and kidney) hemorrhage is often life-threatening and can be difficult to stop in critically ill patients. Traditional techniques for arresting this ongoing bleeding include coagulation by high voltage electrocautery, topical hemostatic application, and the delivery of ignited argon gas. The goal of this study/video was to demonstrate the efficacy of a new energy device for arresting persistent solid organ hemorrhage.A novel instrument utilizing bipolar radiofrequency (RF) energy which acts to ignite/boil dripping saline from a simple handpiece is employed to arrest ongoing bleeding from solid organ injuries in a porcine model. This instrument is extrapolated from experience within elective hepatic resections. An escalating series of injuries to solid organs within a porcine model will be created. This will be followed by arresting hemorrhage with this novel energy device in sequence. A standard suction device will also be employed. This simple saline/RF energy instrument has the potential to arrest ongoing solid organ surface/capsular bleeding, as well as moderate hemorrhage associated with deep lacerations.

The SBRF device described herein provides effective hemostasis for a variety of solid organ injuries. The efficacy of the SBRF device in a porcine model has been described previously8. The results of this study are republished here with permission from the authors.
Using a porcine model, injuries of increasing severity were applied to four separate models. The injuries were described as surface decapsulat...

Watch this Scientific Journal Video about A Saline/Bipolar Radiofrequency Energy Device As an Adjunct for Hemostasis in Solid Organ Injury/Trauma at JoVE.com

A Saline/Bipolar Radiofrequency Energy Device As an Adjunct for Hemostasis in Solid Organ Injury/Trauma

The goal of this publication is to demonstrate the potential application of a novel device using simulated solid organ injuries in a porcine model.

Solid organ (liver, spleen, and kidney) hemorrhage is often life-threatening and can be difficult to stop in critically ill patients. Traditional ...

Life threatening solid organ hemorrhage can be extremely difficult to control. The application of a saline bipolar radio frequency instrument allows the rapid and effective regulation of significant solid organ hemorrhage. This technique is effective for the control of both bleeding, as well as biliary leakage.It's simple to learn, and can be rapidly and effectively performed with minimal formal training. The use of this technique is intuitive. It can be rapidly and effectively applied, even if the practitioner lacks extensive previous experience with the device or extensive knowledge of intro organ anatomy.When the animal is ready, open the hand piece of an ignited SBRF device prepared according to the manufacturer's specifications and connect the handpiece to the generator. Then set the saline flow rate to low and the radio frequency power setting to 160 watts. Establish an adequate exposure of the solid organs of interest, mobilizing other structures and inserting a retractor as necessary.Using a number 10 scalpel blade, apply an abrasive back and forth, one to two millimeter deep, two square centimeter area, superficial force to the liver capsule to induce capsular bleeding. Continue to create one centimeter deep, solid organ lacerations of increasing severity with the scalpel, from five centimeters to the entire length of the liver tissue. Then, using a blunt device such as a Kelly clamp, use a stabbing motion to create penetrating injuries of a partial to full thickness.After simulating all of the appropriate experimental injuries, depress the button of the handpiece to initiate the simultaneous flow of 0.9%saline and the delivery of bipolar radio frequency energy. The saline will boil at the site of application. Position the tip of the device directly onto the raw of the liver surface to superficial areas of bleeding or within defects in the liver itself, and apply concurrent suctioning from a standard surgical aspirator as needed to deliver the heated saline and energy directly to the areas of ongoing hemorrhage.Using a gentle back and forth motion, heat the tissues to approximately 100 degrees Celsius. An auditory pop will occur after three to five seconds. Signifying that the burn is complete.Then move the instrument in an organized manner to the next targeted site, applying precisely directed high voltage electrocautery in conjunction with the application of the SBRF and suction devices to obtain hemostasis as necessary. When all of the sites of the hemorrhage have been cauterized, apply the tip of the device across the injured edge of the liver parenchyma to seal the small to medium bile ducts. In this representative experiment, the depth of the tissue penetration by the SBRF device varied by target organ.Notably, no tissue coagulation was observed when the inferior vena cava was targeted, likely due to the heat sink effect from significant blood flow, which further supports the safety of the device usage around large vascular structures. Saline bipolar radio frequency devices are superb instruments for surgeons who must stop ongoing hemorrhage in challenging areas. They also facilitate primary hemostasis in solid organs without requiring any extensive solid organ anatomy knowledge.

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